Labor and Delivery

1. Timing of delivery. There is little benefit in continuing pregnancy beyond 39 weeks if the cervix is favorable. Induction can be safely delayed until 40 weeks in women with excellent glycemic control, no vascular disease or preeclampsia, normal fetal growth, and no history of stillbirth. Prophylactic cesarean delivery may be considered to prevent brachial plexus injury when the estimated fetal weight is greater than 4500 g.

2. Insulin can be given subcutaneously or by intravenous infusion with a goal of maintaining blood glucose concentrations between 70 and 90 mg/dL. Insulin infusion consists of intravenous administration of 15 units of regular insulin in 150 mL of normal saline at a rate of one to three units per hour.

3. Normal saline may be sufficient to maintain euglycemia when labor is anticipated.

4. As the mother enters active labor, insulin resistance rapidly decreases and insulin requirements fall rapidly. Thus, continuing insulin therapy is likely to lead to hypoglycemia. To prevent this, glucose should be infused at a rate of 2.5 mg/kg per min. Capillary blood glucose should be measured hourly. The glucose infusion should be doubled for the next hour if the blood glucose value is less than 60 mg/dL. On the other hand, values of 120 mg/dL or more require the administration of regular insulin subcutaneously or intravenously until the blood glucose value falls to 70 to 90 mg/dL. At this time, the insulin dose is titrated to maintain normoglycemia while glucose is infused at a rate of 2.5 mg/kg per min.

Low-dosage Constant Insulin Infusion for the Intrapartum Period

Blood Glucose (mg/100 mL)

Insulin Dosage (U/h)

Fluids (125 mL/h)

<100

0

5%dextrose/Lactated Ringer's solution

100-140

1.0

5% dextrose/Lactated Ringer's solution

141-180

1.5

Normal saline

181-220

2.0

Normal saline

>220

2.5

Normal saline

Dilution is 15 U of regular insulin in 150 mL of normal saline, with 25 mL flushed through line, administered intravenously.

5. If a cesarean delivery is planned, the bedtime NPH insulin dose may be given on the morning of surgery and every eight hours thereafter if surgery is delayed. Insulin requirements drop sharply after delivery. The new mother may not require insulin for 24 to 72 hours. Insulin requirements should be recalculated at this time at 0.6 units/kg per day based upon postpartum weight. Postpartum calorie requirements are 25 kcal/kg per day, and somewhat higher (27 kcal/kg per day) in lactating women.

6. Women in whom labor is induced should receive either no morning insulin or only a small dose of an intermediate-acting insulin. Blood glucose monitoring and glucose and insulin infusion are managed as described above for active labor.

H. Postpartum. Insulin requirements drop sharply after delivery; as a result, the new mother may not require insulin for 24 to 72 hours. Insulin requirements should be recalculated at this time at 0.6 units/kg per day based upon postpartum weight and serial blood glucose determinations.

References: See page 184.

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